Effects of public financing of essential maternal and child health interventions across wealth quintiles in Nigeria: an extended cost-effectiveness analysis

Summary Background Maternal and newborn mortality rates in Nigeria are among the highest globally, and large socioeconomic inequalities exist in access to maternal, newborn, and child health (MNCH) services in the country. Inequalities also exist in catastrophic health expenditure among households in Nigeria. We aimed to estimate the health and financial risk protection benefits across different wealth groups in Nigeria if a policy of public financing of MNCH interventions were to be introduced. Methods We did an extended cost-effectiveness analysis to estimate the health and financial risk protection benefits, across different household wealth quintiles, of a public-financing policy that assumes zero out-of-pocket costs to patients at the point of care for 18 essential MNCH services. We projected health outcomes (deaths in children aged <5 years [under-5 deaths] and maternal deaths) and private expenditure averted using the Lives Saved Tool with data extracted from national surveys. We modelled three scenarios: 1) coverage expansion at a rate equal to the trend observed between 2013 and 2018 (status quo); 2) annual coverage expansion by 5% compared with the status quo (uniform scale-up scenario); and 3) annual coverage expansion by 10%, 8%, 6%, 4%, and 2% compared with the status quo from the poorest to the wealthiest quintiles, respectively (pro-poor scale-up scenario). Findings Our analysis shows that, if an additional 5% increase in coverage was provided for all wealth quintiles between 2019 and 2030, this uniform scale-up policy would prevent more than 0·11 million maternal deaths and 1·05 million under-5 deaths, avert US$1·8 billion in private expenditure, and avert 3266 cases of catastrophic health expenditure. The incremental cost effectiveness ratio would be $44 per life-year gained, which is highly cost-effective when compared with the gross domestic product per capita of Nigeria for 2018 ($2028). The policy would prevent a higher number of under-5 deaths and catastrophic health expenditure cases in poorer quintiles, but would prevent more maternal deaths and private expenditure in wealthier quintiles. If poorer populations experienced a greater increase in service coverage (ie, the pro-poor scale-up scenario), more maternal and under-5 deaths would be prevented in the poorer quintiles and more private expenditure would be averted than would be under previous scenarios. Interpretation Public financing of essential MNCH interventions in Nigeria would provide substantial health and financial risk protection benefits to Nigerian households. These benefits would accrue preferentially to the poorest quintiles and would contribute towards reduction of health and socioeconomic inequalities in Nigeria. The distribution would be more pro-poor if public financing of MNCH interventions could target poor households. Funding WHO Partnership for Maternal, Newborn, and Child Health.


Introduction
Despite global progress in improving maternal, newborn, and child health (MNCH), mortality remains high in low-resource settings. In 2019, 53% of global deaths in children younger than 5 years (hereafter referred to as under-5 deaths or under-5 mortality) occurred in sub-Saharan Africa. 1 In Nigeria, maternal and newborn mortality rates are among the highest in the world. 2 In 2018, 80% of married women were at high risk of complications during childbirth and the under-5 mortality rate was 132 deaths per 1000 livebirths. 3 Furthermore, large socioeconomic inequalities exist in MNCH in Nigeria. 4 For example, in the 2018 Demographic and Health Survey, skilled assistance at delivery was documented for 12% of deliveries in the poorest wealth quintile compared with 87% in the wealthiest quintile. 5 If such unequal distribution of service use continues, poor families in Nigeria will continue to lag behind in access to essential MNCH services and in the attainment of the UN Sustainable Development Goals (SDGs).
Considering these inequalities, efforts have been initiated to improve the access to, and affordability of, health services in Nigeria, including the Free Maternal and Child Health Program implemented in 12 states, 5 the National Health Insurance Scheme, and State Health Insurance Schemes. 6 However, service implementation varies across different states and population groups. In 2017, out-of-pocket payments accounted for more than 77% of total health expenditure in Nigeria, and the incidence of catastrophic health expenses, defined as spending more than 10% of household expenses on health care, almost doubled between 2010 and 2016. 7,8 The Nigerian Government allocated only 4·6% of total expenditure to health in 2017, which is lower than the 15% target of the Abuja Declaration. 9 However, the unstable price of oil and the COVID-19 pandemic have had an unpredictable effect on economic growth in the country, making it even more difficult to mobilise and allocate additional resources for health in the country. 8 Thus, it is an important and urgent policy priority for the Nigerian Government to understand how to prioritise and allocate scarce domestic resources for health to achieve maximum benefits for households.
We did an extended cost-effectiveness analysis to estimate the health and financial risk protection benefits across different wealth groups if a policy of public financing of MNCH interventions were to be introduced. Such policy is aligned with the WHO universal health coverage objectives to eliminate user fees at the point of care and improve financial risk protection. Although the costs and health benefits of MNCH interventions have been well reported, few studies have reported the distribution of benefits across wealth groups and few have focused on financial risk protection.

Study setting and assumptions
We did an extended cost-effectiveness analysis of a policy to publicly finance essential MNCH interventions in Nigeria. 10 Compared with traditional cost-effectiveness analyses that estimate the levels of cost and effectiveness of certain interventions, an extended cost-effectiveness analysis further estimates: 1) the distribution of the health benefits across a spectrum; 2) the private health-care expenditure averted by the policy; and 3) the financial risk protection benefits that the policy provides. Under this policy, MNCH interventions are provided to the patient without any cost at the point of care (ie, no out-of-pocket payments). The projection period was between 2019 and 2030 and costs were reported in US$ (whereby $1 was equal to 305·79 Nigerian Naira; 2018 Central Bank of Nigeria rates). Wealth quintiles were defined at the beginning of the projection period and we assumed that an individual's wealth quintile remained stable throughout the projection period. All analysis and projections were conducted using the Lives Saved Tool (version 4.761) and results were reported according to the Consolidated Health Economic Evaluation Reporting Standards checklist. The Lives Saved Tool is a linear, deterministic mathematical model; further details are in the appendix (p 28). The research protocol was reviewed and approved by Duke Campus Institutional Review Board (2020-0122).

MNCH package definition
We selected interventions that met the following inclusion criteria: 1) recommended as priority MNCH interventions

Research in context
Evidence before this study We reviewed documents from WHO, Partnership for Maternal, Newborn, and Child Health (PMNCH), and UNICEF and searched PubMed for articles published in English until January, 2019, using the search terms "public financing", "MNCH" and "economic evaluation". Our search yielded six reports of high-quality research and global estimates about the health outcomes of different maternal, newborn, and child health (MNCH) interventions. We also identified economic evaluations of public financing of MNCH services in Ethiopia, India, and Malaysia. Existing studies showed that public financing of MNCH services could save lives and provide financial risk protection. However, these studies addressed one MNCH intervention or focused on one target population only.

Added value of this study
We estimated the health and financial risk protection benefits across different wealth quintiles if a policy of public financing of MNCH interventions were to be introduced in Nigeria. Our study also addressed a package of 18 MNCH interventions and two key target groups: children younger than 5 years and pregnant women. Our findings contribute to the ongoing discussions about the achievement of the Sustainable Development Goals in Nigeria related to poverty, maternal and child mortality, universal health coverage, and gender equality.

Implications of all the available evidence
Our study found that if a policy of public financing of MNCH interventions were to be introduced, it would save lives, prevent household catastrophic health expenditure, would be highly cost-effective, and would preferentially benefit poorer populations (pro-poor). Additionally, the annual cost of such interventions would be less than 10% of current domestic government spending on health in Nigeria. Our findings imply that public financing of essential MNCH interventions in Nigeria would provide substantial health and financial risk protection benefits to Nigerian households. These benefits would accrue preferentially among individuals in the poorest quintiles and would contribute towards the reduction of health and socioeconomic inequalities in Nigeria. Furthermore, the distribution of health and financial benefits would be more propoor if public financing of MNCH interventions targeted poor households.
by the Partnership for Maternal, Newborn and Child Health (PMNCH), 11 an international multi-stakeholder alliance, including governments, UN agencies, healthcare professional associations, youth-led organisations, and non-governmental organisations; 2) data on coverage for these MNCH interventions available by wealth quintiles; 3) interventions not currently provided for free in Nigeria; and 4) interventions included in the list of Lives Saved Tool's default interventions. We included 18 interventions (panel; appendix p 3).

Baseline data and sources
We divided the total 2018 population of Nigeria (191 million) 12 into five quintiles based on household wealth using 2018 Nigeria Demographic and Household Survey data. 13 For each wealth quintile, we obtained the quintile-specific baseline disease prevalence and service coverage from 2018 Nigeria Demographic and Health Surveys and Nigeria Multiple Indicator Cluster Surveys, 4,13 and estimated the average annual rates of change (AARC) for each quintile using the quintilespecific data from the previous two surveys (appendix p 5). Proxies for service coverage were used when no reliable data were available (appendix p 6). We adjusted the default settings of the Lives Saved Tool for target population and population in need by using quintilespecific estimates for total fertility rates, proportion of women with low BMI (<18·5 kg/m²), neonatal mortality rates, infant mortality rates, and under-5 mortality rates (appendix p 7).

Modelled scenarios
We modelled three scenarios: 1) coverage for interventions will expand at an AARC equal to the trend observed between 2013 and 2018 (referred to hereafter as status quo; appendix p 9); 2) coverage will increase by 5% compared with the status quo scenario every year 14 (referred to hereafter as the uniform scale-up scenario); and 3) coverage will increase by 10%, 8%, 6%, 4%, and 2% compared with the status quo from the poorest to the wealthiest household quintiles, respectively, every year (referred to hereafter as the pro-poor targeted scale-up scenario). For all three scenarios, if coverage reached 95%, it would remain stable until the end of the projection (appendix pp 9-21).

Estimation of outcomes
Health outcomes were the number of under-5 deaths and maternal deaths averted and life-years gained. We modelled deaths averted using the Lives Saved Tool. To estimate life-years saved, for under-5 deaths, we multiplied  the number of deaths averted at age 5 by the remaining life expectancy at age 5, and for maternal deaths (ie, among women of reproductive age), we multiplied the number of deaths averted at 30 years (midpoint between 15 and 45 years) by the remaining life expectancy at 30 years. 10 The Lives Saved Tool estimates costs on the basis of a target population, proportion of population in need, coverage, treatment inputs, and cost per service. The Lives Saved Tool methodology has been published previously (appendix p 29). 15, 16 We reported the intervention cost from the Lives Saved Tool, which included health-care provider fees, diagnostic costs, and medication costs, but excluded indirect costs such as transportation costs or the opportunity cost of lost employment or wages (appendix We applied a scale-up cost of 20% to estimate the total health system cost of the policy. Private expenditure refers to pooled resources that are not controlled by the government, such as voluntary health insurance, and direct payments or out-of-pocket payments from households. In Nigeria, voluntary health insurance accounted for only 0·55% of current health expenditure in 2018. 9 Therefore, to estimate the private expenditure averted, we used the total cost of interventions from the Lives Saved Tool, and multiplied the cost by the current out of-pocket payment ratio in Nigeria (77%). We defined catastrophic health expenditure as private expenditure for health expenditures that exceeded 10% of household income. 17 We used the private expenditure for each intervention to estimate whether this intervention could lead to catastrophic health expenditure and accumulated the number of catastrophic health expenditure cases for each intervention. We used the income information from the Nigeria Living Standards Survey, disaggregated by wealth quintiles 18 (appendix p 8). Incremental cost-effectiveness ratios were reported from a modified societal perspective that includes the perspective of the payer and the household.
We conducted a sensitivity analysis of the effect of the total fertility rate on estimates, to assess the effect of quintile population size and population growth rate. We repeated our analysis with different total fertility rate assumptions (using fertility rates 10% lower and higher than estimated fertility rate and using the national mean total fertility rates for each quintile). We also conducted sensitivity analyses on discount rates (at 3%, 5% and 10%), scale-up costs (at 10%, 30%, and 40%), and service coverage levels (at 4% and 6%).

Role of the funding source
The study funder was involved in study design, but had no role in data collection, data analysis, data interpretation, or writing of the report.

Results
Our model estimates a total number of under-5 deaths over the 12-year period of 11·5 million in the status quo scenario, 10·4 million in the uniform scale-up scenario, and 10·1 million in the pro-poor scale-up scenario. Over the same period, we estimate that maternal deaths would be 0·79 million in the status quo scenario, 0·68 million in the uniform scale-up scenario, and 0·67 million in the pro-poor scale-up scenario (table 1) (table 2). However, the distribution of averted maternal deaths would not be pro-poor under the uniform scale-up scenario: the two poorest quintiles would account for only 22·8% of averted deaths, whereas 54·2% of all maternal deaths averted would be among the wealthiest two quintiles. Compared with the status quo scenario, 38·6% of total maternal deaths would be averted among the two poorest quintiles under the pro-poor scale-up scenario, with a higher proportion of maternal deaths averted than in the status quo scenario (table 2; appendix p 15).
Different interventions would have different effects on the number of under-5 deaths averted overall and by wealth quintile (appendix pp 9, 15). Skilled birth assistance at delivery would prevent the most under-5 deaths (350 000), followed by provision of oral rehydration solution (252 000).
Overall, compared with the status quo scenario, the uniform scale-up scenario would save $1·77 billion in private expenditure between 2019 and 2030 (   (table 5). Compared with the status quo scenario, the incremental cost-effectiveness ratio (ICER) under the pro-poor scaleup scenario would be $2384 per life saved. Our results suggest that the policy to publicly finance MNCH interventions would be more cost-effective in poorer quintiles than in wealthier quintiles. Chlorhexidine would be the most cost-effective intervention with the lowest ICER for children younger than 5 years and case management for hypertensive disorders in pregnancy would be most cost-efficient for pregnant women. By contrast, supplementary feeding and education would be the least cost-effective interventions for children younger than 5 years and iron supplementation in pregnancy for pregnant women (appendix p 13).
Sensitivity analysis found that when the total fertility rate increased by 10%, the national estimates of deaths averted and private expenditure averted increased by around 9·6% and when total fertility rate decreased by 10% estimates of deaths averted and private expenditure averted decreased by around 9·6%, with little variation across quintiles. ICERs would remain almost the same (appendix p 24). If we assume that all quintiles have the national average total fertility rate, the total number of deaths averted would decrease by 5·1% and private expenditure by 4·5%, with substantial variation among the different quintiles and the ICER would increase by 0·6% (appendix p 24). Sensitivity analysis of discount rates found that if a 3% discount was applied, the private expenditure averted and the ICER would increase by 30·9% with little variation across quintiles. The ICER for discount rates at 3%, 5% and 10% would be $3071, $3645, and $5573 per life-year saved, respectively (appendix p 25). Sensitivity analysis of scale-up costs found that if scale-up cost increased or decreased by 10%, it would lead to about 8·3% increase or decrease in ICER, respectively, while total lives saved and private expenditure averted would remain stable (appendix p 26). If scale-up rate was 4% per year, 15·1% fewer deaths would be averted and there would be a 15·6% decrease in private expenditure averted. By contrast, if scale-up rate was 6% per year, the total number of deaths averted would increase by 19·3% and private expenditure averted would increase by 16·5% (appendix p 27).

Discussion
Our study found that a policy to provide public financing for priority MNCH interventions in Nigeria has the potential to save lives and prevent catastrophic health expenditure, would be highly cost-effective, and would have a pro-poor distribution.
Our results support findings from other evaluations of public financing of MNCH services in resource-poor settings. For example, Nandi and colleagues found that scaling up of a home-based neonatal care package in rural India through public financing would prevent five deaths  and provide $285 of insurance per 1000 livebirths, with most benefit for poor families. 19 Other studies found public financing for rotavirus vaccinations would decrease deaths and impoverishment in poorer quintiles in Ethiopia and India, 20,21 and in Malaysia it would provide financial risk protection across all quintiles. 22 Although the findings of these studies strengthen our findings, each study addressed a single MNCH intervention or focused on one target population. By contrast, our study addresses a package of MNCH interventions and two key target groups-children younger than 5 years and pregnant women.
Additionally, our study focuses on Nigeria, a country that accounts for a substantial proportion of the global burden of maternal mortality, 23,24 under-5 mortality, 25 and poverty. 26 Our findings suggest that investment in public financing for MNCH could reduce mortality and alleviate poverty, providing an important contribution to ongoing policy discussions about the best approaches for achieving the SDG goals for poverty, health, and gender equality in Nigeria, and as the Lancet Nigeria Commission suggested, prioritisation of health could be the first place to start. 27 It is important that decision makers explore policies that provide both health and financial benefits to women and children who are the most susceptible to the health and financial risks of seeking and of forgoing essential health care. 28,29 Our study estimated that the cost of publicly financing 18 MNCH interventions would be less than $2374 per death averted, or $44 per life-year gained, which is highly cost-effective when compared with the gross domestic product (GDP) per capita of Nigeria ($2027 in 2018; WHO recommends three times GDP as the threshold for cost-effectiveness 30 ). We also found that most of the 18 MNCH interventions included in our study were pro-poor and that implementing a policy of publicly financing these interventions would improve access and reduce health disparities in Nigeria. The total health system cost of providing 18 interventions between 2019 and 2030 would be $2·76-3·51 billion, translating into a mean annual cost of $0·23-0·29 billion, equating to less than 10% of the current domestic government spending on health in Nigeria ($2·3 billion in 2019).
At present in Nigeria, coverage of health services is higher among wealthier quintiles, whereas the poorest quintile has the least coverage. Thus, there is an opportunity for considerable improvement in the service coverage for the poorest populations. Different findings from two scenarios suggested that if the policy could reach poor populations, better health outcomes and financial risk protection would be achieved. Additionally, the health benefits and financial risk protection would have a stronger pro-poor distribution. In reality, the propoor targeted scale-up scenario could be implemented by targeting populations in less developed areas, such as the rural regions or lowest-income districts or states. In 2019, the Basic Healthcare Provision Fund (BHCPF) was launched in Nigeria to provide universal health coverage to citizens. BHCPF currently prioritises people living in poor households through geographical targeting and coverage of services preferentially used by poorer populations. At primary health-care centres, BHCPF covers the cost of antenatal care, delivery, and postnatal care for pregnant women, pneumonia treatment, diarrhoea treatment, and malaria treatment for children younger than 5 years. 31 BHCPF could therefore be the vehicle for the implementation of the pro-poor scenario. However, for policy implementation to be successful, problems that have affected previous free (at the point of care) maternal and child health programmes must be addressed. Onwujekwe and colleagues assessed one such free programme and identified corrupt practices, scarcity of medical supplies, and weak public financial management as barriers that prevented the programme from achieving the intended effect. 5 The Nigerian Government committed $2·3 billion to the PMNCH Call to Action on COVID-19 for 2020-28 for strategic interventions, which could potentially improve access to MNCH services while reducing health inequalities.
Our study has several limitations. First, due to difficulties in obtaining disaggregated data by socioeconomic quintile for all MNCH interventions recommended by WHO, we only included a package of   18 MNCH interventions in this analysis. This relatively small number of MNCH interventions with reliable disaggregated data indicates the importance of bridging the data gap for MNCH interventions. Additionally, there might be gaps in implementation of interventions currently being offered for free and efforts to expand the scope of MNCH services, under considerable resource limitations, should be balanced against efforts to improve access and quality of services that are currently offered. Second, our study assigned wealth quintiles at baseline (in 2018) and quintiles were considered as cohorts for the period 2019 to 2030. Thus, we assumed that all individuals and families remained in the same wealth quintile for a period of 12 years, which might not be the case for some individuals or families. However, since we used relative socioeconomic measures rather than absolute measures, we controlled for the assumption that as absolute conditions (eg, wages) change for most members of society, relative conditions (compared with others) would on average remain the same. Third, our study focuses on MNCH interventions in Nigeria and might not be generalisable to other countries with different patterns of disease, health seeking behaviours, and socioeconomic characteristics. Fourth, the Lives Saved Tool is a deterministic model and we used the national estimate of population in need in the Lives Saved Tool for all quintiles, which might not reflect the real situation. We reported lives saved (deaths averted) but quality of life was not considered. Fifth, our study did not consider quality of care, effective coverage, or other factors that would affect service use such as direct non-medical costs (eg, cost of seeking care) and indirect costs (eg, lost wages), but we acknowledge the possibility that public financing of MNCH interventions might improve access or induce demand, but not necessarily improve the actual service use or quality.
In summary, this study shows that a policy to publicly finance priority MNCH interventions in Nigeria could bring additional health benefits and financial risk protection for all for an annual increase of 10% in the government health budget. Additionally, the distribution of the health benefits (under-5 and maternal deaths averted) and financial benefits (private expenditure averted and financial risk protection afforded) of this policy would be pro-poor. The distribution of health and financial benefits would be more pro-poor if public financing of MNCH interventions was targeted at poor households. Therefore, as Nigeria continues to deal with high maternal mortality, high under-5 mortality, and high levels of poverty, decision makers should strongly consider policies such as public financing for MNCH services that will result in progress towards achieving SDG targets for health, poverty, and gender equality. Protecting funding for these essential MNCH services should be prioritised to improve the lives of women and children and to reduce the inequalities in health and economic outcomes that exist in Nigeria.

Contributors
OO led the overall design of the study with inputs from all authors. WM collected the data, and performed the analysis with support from OO and DW. WM drafted the initial manuscript. All authors contributed to revision of the manuscript and approved of the final version.

Declaration of interests
MLS was an employee at the Partnership for Maternal, Newborn and Child Health (PMNCH) hosted by WHO during the execution of this research; she is currently an employee at The Lancet, but was recused from all editorial discussions about this manuscript. MS reports grants from PMNCH, Bill & Melinda Gates Foundation, Save the Children, Plan International, and WHO. OO reports grants from PMNCH during the conduct of the study; grants from the Gates Foundation, the National Institute of Minority Health and Health Disparities, WHO, and Gavi, the Vaccine Alliance; and personal fees from PMNCH and Save the Children outside the submitted work; and is a member of the Merck for Mothers Strengthening Systems for Safer Childbirth Advisory Committee and the Africa CDC Health Economics Unit Technical Advisory Group (both unpaid). All other authors declare no competing interests.

Data sharing
This study made use of publicly available data. The appendix describes the data sources and methods used in detail.